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r CONTRACTOR'S CERTIFICATION : r UNDER PENALTY OF PERJURY , the undersigned CONTRACTOR certifies that ( 1 ) all previous progress payments received from OWNER on account of Work done under the r Contract referred to above have been applied on account to discharge CONTRACTOR' s legitimate obligations incurred in connection with Work covered by prior Applications for Payment numbered 1 through inclusive ; (2) title of all Work, materials and equipment r incorporated in said Work or otherwise listed in or covered by this Application for Payment will pass to OWNER at time of payment free and clear of all Liens, security interests and encumbrances (except such as are covered by a Bond acceptable to OWNER indemnifying OWNER against any such Lien , security interest or encumbrance); (3) all Work covered by this r Application for Payment is in accordance with the Contract Documents and not defective and (4) If this Periodic Estimate is for a Final payment to project or improvement, I further certify that all persons doing work upon or furnishing materials or supplies for this project or improvement r under this foregoing contract have been paid in full , and that all taxes imposed by No. 212 Florida Statutes, (Sales and Use Tax Act, as Amended) have been paid and discharged , and that I have no claims against the OWNER. r Dated (CONTRACTOR) r By State of County of • Subscribed and sworn to before me this day of Notary Public My Commission expires: r CERTIFICATION OF ARCHITECT OR CONSULTING ENGINEER (WHERE APPLICABLE) : I certify that I have checked and verify the above and foregoing Periodic Estimate for Partial Payment; that to the best of my knowledge and belief it is a true and correct statement of the work performed and/or material supplied by the Contractor. Dated r (ARCHITECT / ENGINEER) SIGNATURE CERTIFICATION OF ENGINEER / INSPECTOR: I have checked the estimate against the Contractor's Schedule of Amounts for Contract Payments and the notes and reports of my inspections of the project. It is my opinion that this statement of work performed and/or materials supplied is accurate, that the Contractor is observing the requirements of the Contract, and that the Contractor should be paid the amount requested above. r Dated (ENGINEER/INSPECTOR) SIGNATURE Accompanying Documentation : l7he Remainder of Page Intentional Left Blankl 00622 - Contractor's Application for Payment REV 04-07.doc i" 00622 - 2 FAEriglneenngtCapital Projer k%11-CR 512 Widening19611 CR 512 PHASE N,Contraa Dowments100622 - Contractors Application for Payment REV 0"7.doc